This study explored if a youth-specific mental health service routinely set goals with young people during initial intake/assessment and if goal setting and goal quality in this service was associated with patient retention.
Cairns et al Child Adolesc Psychiatry Ment Health (2019) 13:31 https://doi.org/10.1186/s13034-019-0288-x Child and Adolescent Psychiatry and Mental Health Open Access RESEARCH ARTICLE Goal setting improves retention in youth mental health: a cross‑sectional analysis Alice J. Cairns1* , David J. Kavanagh2, Frances Dark3,4 and Steven M. McPhail5,6 Abstract Background: This study explored if a youth-specific mental health service routinely set goals with young people during initial intake/assessment and if goal setting and goal quality in this service was associated with patient retention Methods: Consecutive initial assessments (n = 283) and administrative service data from two youth-specific health services in Australia were audited for evidence of goal setting, content and quality of the goal and number of therapy services provided after the intake/assessment process Logistic regression was used to determine if goal setting was associated with disengagement after the assessment session, controlling for drug use, unemployment, age, gender, mental health diagnosis and service site A consecutive sub-sample of 166 goals (74 participants), was analysed for goal quality Each goal was assessed against three components of the SMART (specific, measurable, acceptable/ achievable, realistic and timed goals) criteria; specific, measurable and timed; and assigned a goal quality score 1–3 A multiple regression explored whether goal quality was predictive of the number of sessions attended, controlling for the same variables as the logistic regression Results: Goal setting was evident in the records of 187 participants (66%) Although most goals were for emotional management, 24% addressed improvements in function Of the 166 goals analysed in depth, 95 were specific, 23 measurable, but none were timed Not setting goals during initial assessments correlated with service disengagement (OR 0.30, p > 0.001) Goal setting was positively associated with more therapy sessions attended, regardless of goal quality rating Conclusions: Engagement and retention of young people within mental health services can be challenging Clinical tools such as goal setting may keep young people engaged in services longer, potentially improving clinical outcomes Further research exploring the effectiveness of current youth service models on client-specific goal based outcomes is recommended Keywords: Youth mental health, Goal setting, Retention, Disengagement, SMART Introduction Having a goal and writing it down are two important tasks anyone can to improve the likelihood of achieving a desired outcome Goal setting is regularly used by mental health and rehabilitation professionals to focus service provision on functional outcomes that are meaningful to the consumer [1, 2] Goal setting can also support recovery through individualisation of outcomes [3] *Correspondence: alice.cairns@jcu.edu.au Centre for Rural and Remote Health, James Cook University, PO Box 341, Weipa, QLD 4874, Australia Full list of author information is available at the end of the article Goal setting might be especially relevant for young people accessing youth mental health services This group experiences high rates of distress, disability and restricted social participation, as evidenced by their high rates (19–33%) of not being in employment, education or training compared with 14% of the general population of 20–24 year olds [4–6] Meaningful change in social participation, rather than just psychological symptom relief, is a key aim of youth-specific mental health services [7–9] The extent these services are achieving this aim is unclear [10] Patient-specific outcomes like goal-based outcomes may offer a clinician and youth friendly solution to this © The Author(s) 2019 This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated Cairns et al Child Adolesc Psychiatry Ment Health (2019) 13:31 problem [11] Although goal setting is common practice in delivering psychological therapies to youth [2], the influence of goal setting on motivation and clinical outcomes within this population have not been well established [12] In other fields, goal quality does appear to have an impact on immediate performance of tasks aimed at achieving that goal In cerebrovascular rehabilitation settings, patients with functional, measurable goals at service entry tend to have higher discharge scores on functional measures than ones who made general goal statements [13]; and specific, challenging goals improved immediate performance in cognitive and motor tasks [14] In non-clinical settings, specific and challenging goals have been associated with greater effort and persistence from goal setters in comparison to vague or ‘easy’ goals [15] This demonstrates the potential influence on specific tasks necessary for goal achievement However, there is no clear evidence that goal setting influences retention of patients within a service This is a particularly pertinent issue in youth mental health, where attrition before treatment completion is common [16] This investigation explored the routine use of goal setting with young people experiencing mental health issues during the first use of a youth-specific mental health service This study explored whether the occurrence and quality of goal setting are associated with subsequent patient retention This aim of this investigation was to: a identify if goal setting was occurring during the initial intake and assessment process and what demographic variables may be associated with goals being set; b explore the quality of the goals being set and pilot a quality index score and; c identify if the presence or quality of goals was associated with the level of patient retention Methods Design, participants and ethical approval This cross-sectional investigation audited 283 consecutive clinical charts from young people aged 12–25 years old accessing a non-government youth mental health service (headspace) in 2016 Ethical approval was granted by the Queensland University of Technology (Approval Number 1400000066) Setting Two headspace centres in South East Queensland, Australia participated in this study headspace is an Australian-wide initiative with over 100 centres spread throughout the continent headspace provides services to 12–25 year olds with the primary aim of promoting and Page of supporting early intervention for mental health issues as well as general health, vocational and substance use problems [7] Referrals are received from young people themselves (self-referral), parents/guardians, general practitioners and other health professionals, tertiary government mental health services, schools or community based organisations, and family or youth courts headspace, clinicians will refer to tertiary government mental health services if the mental health needs of the young person are specialised or the person is at immediate risk to themselves or others Young people seeking help from a headspace centre have at least one initial intake and assessment session to determine the individual’s needs and suitability for the service If considered appropriate after the initial assessment, they are referred to a headspace therapist to provide ongoing mental (or physical) health services [17] Young people can be involved with other clinical or vocational programs while engaged with headspace headspace, has a ‘no wrong door’ policy meaning young people can present or be referred for any issue without having to negotiate complex inclusion/ exclusion service criteria [18] Procedure Initial intake, assessment and administrative service data from consecutive charts were audited by one member of the research team with support from a second member to check and clarify any ambiguous data Support from a headspace clinician at each site was also available to clarify any ambiguous clinical notes Basic demographic and clinical data including age (in years); gender (M/F); self reported current or previous drug use (yes/no); documented mental health diagnosis (yes/no); whether the participant was employed or studying (yes/no), were collected from the participants’ clinical intake and assessment information Administrative data for each participant included the total number of therapy sessions attended after the initial intake/assessment process (patient retention) and the headspace site the participant sought help from Service disengagement If no therapy sessions were attended after the initial assessment, this was classified as service disengagement (coded yes/no) This portion of the sample was of particular interest to the research team Patient charts were scanned for a stated reason for not continuing with the service Goal setting During intake and assessment sessions, service intake clinicians are expected to elicit what the young person hopes to achieve by attending the service (goals) To Cairns et al Child Adolesc Psychiatry Ment Health (2019) 13:31 identify if goal setting occurred, all intake and assessment clinician notes were reviewed by a health professional independent of the clinical team Goals for therapy or service engagement were typically documented at the end of the clinical assessment document; however, the entire assessment notes were audited to ensure goals recorded elsewhere were not missed The presence of goal setting was recorded as a dichotomous variable (yes/no) Goal content and quality The content of a sub-sample of 74 consecutive charts with a documented goal was examined Goals from these charts were recorded verbatim for assessment of content and quality Goal content was coded into pre-specified categories derived from previously reported reasons for help-seeking and functional concerns [5, 19] Goals were allocated to one category only Potential categories were: Emotional management, relationship/interpersonal, vocational (school/work), living skills (e.g housing, life planning), alcohol/drug related and physical health (including sexual health) An ‘other’ category was included for goals that did not fit into any of the above categories If a goal could plausibly be linked to more than one category, it was allocated to the category that corresponded to the intended outcome For example, one participant’s goal was to ‘manage social anxiety to stay employed’ This goal would potentially fit both in the emotional management and vocational categories Because the participant identified the intended outcome was to remain employed, the goal was allocated to the ‘vocational’ category Goal quality was determined by analysing each goal against the SMART (specific, measurable, achievable, realistic/relevant and timed) framework for goal setting [20] Because of the complexity and personal nature of determining if a goal was realistic or achievable (which the investigators did not believe could be judged from the information available), those components were not included in the analysis Therefore, goals were assessed by a yes/no outcome on being: • Specific—did they define exactly what is being pursued? • Measurable—was there a clear way to track completion? • Timed—is there any reference to time frame? Goal quality analysis was conducted by the first author and was reviewed by another member of the research team for accuracy A third member of the research team was available to arbitrate disagreements, but this was not required To predict the influence of goals and goal quality on the sum of sessions attended, goals were allocated a Page of quality index score, piloted in this study This scores were: (no goals recorded), (goals were reported but did not adhere to any SMART category), (at least one goal set per participant was specific), (at least one goal set was specific and measurable), and (at least one goal set was specific, measurable and timed) Analysis To explore potential variables associated with the presence of goals during the initial assessment, univariate logistic regressions were used to explore if the presence of goal setting (dichotomous outcome variable) was associated with age, gender, work/study status, history of drug use, mental health diagnosis, service disengagement or the service site Service disengagement data were not available for nine participants, because the reason for disengagement was outside of the control of staff or participants Reasons included unsuitability for the service and referral elsewhere (e.g to a tertiary mental health service; n = 5); moving outside of the service catchment areas (n = 3); not being an Australia citizen and therefore being ineligible to access services through the primary service delivery model (n = 1) Explanatory variables with p